36C25627Q0087 EXHIBIT D.docx
DOCX document 32 KB Posted
- Solicitation number
- 36C25627Q0087
About this file
This is a Contractor Evaluation Form for construction safety used in the evaluation of offers for solicitation 36C25627Q0087, a turnkey chiller equipment purchase and installation project for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16. The form requires offerors to provide detailed safety performance data from their OSHA 300 Forms covering three years (2023, 2024, and 2025), including total man hours, number of cases involving days away from work or restricted activity, the Days Away, Restricted, or Transferred (DART) rate, and the number of serious, willful, or repeat OSHA violations incurred within the past three years with explanatory documentation for any violations cited.
Additionally, offerors must identify the individual or department administering their company's Safety and Health Program and provide their current Insurance Experience Modification Rate (EMR) obtained from their insurance carrier on official letterhead. If the EMR exceeds 1.0, offerors must submit a written explanation from their insurance carrier detailing the reasons for the elevated rate and the anticipated timeline for reduction to 1.0 or below. Offerors are required to attach copies of their OSHA 300 and 300a Forms along with all supporting documentation to complete this evaluation criterion.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25627Q0087 0001.docx | DOCX document | |
| 36C25627Q0087 EXHIBIT B.docx | DOCX document | |
| LA20260031.pdf | ||
| 36C25627Q0087 EXHIBIT C.docx | DOCX document | |
| Final OR CHILLER REPLACEMENT SOW.docx | DOCX document | |
| 36C25627Q0087.docx | DOCX document | |
| 36C25627Q0087 EXHIBIT E.docx | DOCX document | |
| JA- BRAND NAME s.pdf | ||
| 36C25627Q0087 EXHIBIT A.docx | DOCX document |
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 CON HVAC Replacement 36C25627Q0087
Exhibit D Contractor Evaluation Form Construction Safety
Company Name:
Address:
Telephone: Fax:
Email:
Contact:
1. Utilizing your OSHA 300 Forms, please complete the following information:
| Category |
| 2023 |
| 2024 |
| 2025 |
Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanations for any violations.
Please attach copies of the following documents: OSHA 300 and 300a Forms.
These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
| 2. | Who administers your company’s Safety and Health Program? |
| 3. | Company’s current Insurance Experience Modification Rate (EMR): |
The above EMR rate must be obtained from offeror’s insurance carrier and furnished on insurance carrier’s letterhead. If EMR is greater than 1.0, attach a written explanation of the EMR from insurance carrier on insurance carrier’s letterhead describing the reasons for the EMR and the anticipated date the EMR may be reduced to 1.0 or below.
File details come from the government source that posted it. Updated .